When Symptom Normalization Becomes a Barrier to Care

Reassurance of patients that their symptoms are “normal” may lead patients to infer that treatment is not necessary, according to a study published online Aug. 10 in Nature Human Behaviour.

Seyi Lawal, from the University of California in San Diego in La Jolla, and colleagues address the phenomenon of reassurance that symptoms are normal reducing people’s inclination to pursue treatment. Reassurance through normalization was documented in 14 studies involving 9,371 participants.

The authors note that normalization triggers a reappraisal of treatment norms, with patients inferring that symptom normalization by health care providers is intended to communicate that treatment is not warranted. Communication strategies to overcome this incorrect inference were explored, including pairing normalizing language with a specific recommendation for treatment, and explaining that “normal” was meant in a statistical sense, rather than normative.

“Doctors usually have a noble goal. They mean to ease anxiety, but somehow it backfires,” senior author On Amir, Ph.D., also from the University of California San Diego, said in a statement. “Doctors shouldn’t stop reassuring patients. But they should make their meaning unmistakable.”

When “Normal” Symptoms Aren’t Normal for the Patient

The term “normal” can mean different things to a provider and a patient. A symptom may be common without being something a patient should simply tolerate or ignore.

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For Black patients in particular, their complaints may be dismissed or misdiagnosed as another medical problem by some healthcare providers.

For example:

• Chronic pain being attributed to something patients are simply expected to live with.
• Heavy menstrual bleeding being normalized rather than investigated.
• Symptoms of conditions such as endometriosis or fibroids being dismissed.
• Persistent cardiovascular or neurological symptoms being attributed to stress, aging, weight, or other factors without sufficient evaluation.

Studies show that Black women experiencing chronic pelvic pain had frequent experiences of both dismissal and normalization of symptoms by clinicians.

For providers, it’s critical to understand that symptoms can be common without being clinically insignificant.

For Black Patients, Dismissal Can Become Another Barrier to Care

While the researchers didn’t specifically study Black patients, its findings take on additional significance in populations that already report experiences of having symptoms being minimized or dismissed. Over time, when patients repeatedly hear that a symptom is normal, they may become less likely to bring it up again, seek a second opinion, or pursue additional evaluation. For patients who have already experienced being unheard in healthcare settings, reassurance without clear next steps may reinforce the belief that their symptoms aren’t worth bringing back to a clinician.

How Providers Can Reassure Without Dismissing Symptoms

When listening to a patient explain their symptoms, it’s critical not only to be an active listener, but also to distinguish between reassurance and treatment guidance.

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Below are some effective communication strategies clinicians can adopt to ensure patients feel heard rather than dismissed:

• Instead of: “That’s normal.”
• Consider: “That symptom can be common, but I want to make sure we know what’s causing it.”

• Instead of: “That’s just a part of aging.”
• Consider: “Some changes are common as you get older, but let’s discuss whether what you’re experiencing falls within that expected range.”

• Instead: “There’s nothing to worry about.”
• Consider: “I don’t see any signs that indicate this is an urgent issue right now, but I’d like for you to monitor it and contact me if anything changes.

Instead of just normalizing symptoms, patient reassurance should include the following components:

• What the clinician means by “normal.”
• Whether treatment or monitoring is still appropriate.
• What symptoms should prompt follow-up.
• When the patient should return or seek additional care.

Listen for What Patients Mean by “Is This Normal?”

When a patient asks, “Is this normal?” they may really be asking their provider:

• “Should I be concerned?”
• “Do I need treatment?”
• “Am I overreacting?”
• “Should I come back if this continues?”
• “Is this something I should have been concerned about sooner?”

For clinicians, symptom normalization should reduce unnecessary worry, not unintentionally reduce appropriate care-seeking.

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